Ode To My Graduates: From Your Faculty Member

“Congratulations! Today is your day.

You’re off to Great Places! You’re off and away!”1


You’re off to new places, different and scary,

You’ll be all alone when cases get hairy.

You’ll be the last call, where the buck finally stops.

You’ll make the tough calls in all your new shops.


Are you frightened? I would be. Nervous? You should be.

Some patients will die though you’re the best that you could be.

Some patients will gripe though you’re always caring.

Some patients will thank you, but those will be sparing.


You’ll have grave misgivings after calling a code.

You’ll also lose sleep over ones you sent home.

You’ll log in to EPIC each morning to see things

Like whether that patient you tubed is now breathing.


But all of those worries simply go to show

that you are good doctors, and all of you know

What to do when quick thinking and action are needed,

When to transfer patients you’ve triaged and treated.


You know when to fight to get what is best,

And when to put challenging cases to rest.

You can diagnose problems when others have missed ’em.

You know how to work in a broken health system.


You know how to care for the various pains,

Of rhomboid and deltoid and inner groin strains.

You can set broken bones, diagnose injured brains.

Repair lacs, reduce joints, do incisions and drains.


You can take care of patients who are having MIs,

or CHF, CVAs, and URIs,

TIAs, GSWs, and PFOs,

UTIs, STIs, and those DFOs.


10 smart docs, you know what you’re about,

When things go south you can say without doubt,

That you did your best, you did what you should.

You tried your hardest, you did all you could.


But it’s also important you care what you do,

That you don’t let the stress and the strife get to you.

When you tell a new mother her child is ill,

A burden that you cannot cure with a pill.


When you explain why colds don’t need antibiotics,

Or why you’re not willing to prescribe more narcotics.

These conversations take patience and love,

And in those areas you’re three cuts above.


If you’re ever unsure about what you should do,

When pressures are mounting to move patients through,

When the hospital’s full and the waiting room packed-in,

And five EMS trucks have just then backed in,


If the system abusers with chronic conditions,

Who come for the five hundred thousandth admission,

Make you feel as if you can take it no longer,

Your compassion’s fatigued where it used to be stronger.


If core measures and metrics are things you abhor,

If admin and charts grind you into the floor,

If bean counters keep showing patients the door,

And with less time and money, demand you do more.


If door to doc times carry more bearing

Than talking to patients, compassion, and caring,

First and foremost, and come what may

Do what’s right for the patient, each shift, and each day.


Remember why you went into it all:

To help people be healthy. And always recall

The training you received and your residency,

Where you are still family to the faculty.


We’ve worked alongside you, these last few years,

We’ve watched you gain skills through smiles and tears,

And at ACEP in Boston, we shared a few beers.

So tonight is for you! Well done and three cheers.


You’ve touched hundreds of lives. You’ll touch thousands more.

You’re board eligible when you walk out this door.

You’ve more wits and smarts than the average MD.

And you should be proud of all you’ve achieved.


You’re well trained, you’re quick, and you’re ready to go.

Your futures are bright! And one thing you should know:

No matter how near or how far you may stray

Remember, we’re only a phone call away.


So be your name Pemberton, Lentz, or Lu,

Montoya, Bria, Jones, or, Matthews,

Pisula, Armstrong, or finally True,

We all simply couldn’t be prouder of you.


1 Opening stanza from “Oh the Places You’ll Go ” by Dr. Seuss, Random House Publishing, 1990

Image(s), used under license from Shutterstock.com

The post Ode To My Graduates: From Your Faculty Member appeared first on FemInEM.

5 Ways to Geriatricize Your ED

800px-Clock_CogsGeriatric EDs, or Senior EDs, have been popping up around the country. The idea behind them is that having a separate space, a distinct staff, and specialized protocols, can help provide better care to older adults. However, for many EDs and hospital systems this is simply not feasible. In this episode, Chris Carpenter (@GeriatricEDnews) presents five high-yield, low-cost ways that those of us working in non-senior EDs can take some of the principles of geriatric emergency medicine and apply them either to our own practice or implement them in our own EDs, without a lot of funding. For more about Geriatric EDs, check out this ALiEM blog post.

To learn more about many of the Geriatric EM ideas and concepts discussed here, check out the Geri-EM.com site, where you can also get free CME.

  1. Distinguish Geriatric ED Model from Traditional Model.Know that there is a model of care [1] for Geriatric Emergency care, defined by the Geriatric ED Guidelines. They are free, easily accessible, and pragmatic and consist of 42 evidence-based guidelines for care. They discuss the importance of understanding co-morbid illness, geriatric syndromes (delirium, demenia, fall risk, polypharmacy, frailty) [2], psychosocial constraints, some unique protocols and infrastructure [3] and team-based approaches [4,5].
  1. Functional Assessment. When a patient comes in with a fall, and you notice they’ve been there many times before with falls, in what ways could you go the extra step to do what you can to help prevent future falls? This may mean helping them get PT/OT or a home assessment, depending on your resources available. Or it may mean counseling the patient, or doing a good med rec. Few general ED providers document baseline functional capacity such as falls or gait assessment but EDs focused on older adults often do. Approximately 1-in-3 community-residing adults over age 65 suffer standing level fall annually, but few receive guideline-directed fall prevention measures and fall-risk stratification is in infancy. As many as 1-in-3 non-injurious fall victims discharged home experience significant functional deterioration within 3-months [11]. However, knowing which individual patients fall into that group, and whether the deterioration is preventable is more difficulty [12].One tool to risk-stratify patients for their risk of a fall in 6 months is the following 4-item questionnaire:
    1. Presence of non-healing foot sore?
    2. Any fall in the last 12 months?
    3. Inability to cut their own toenails?
    4. Self-reported depression?

A score of one or more “yes” responses in a community dwelling older adult indicates a higher risk of future falls.

A falls evaluation should consider at least the following four factors: the causes (intrinsic and extrinsic), the consequences, a safe discharge assessment, and potential ways of preventing future falls [3]

  1. Cognitive Assessment. Approximately 30%-40% of community-dwelling adults over age 65 in the ED will have dementia or mild cognitive impairment if formally assessed [13] and 10% will have delirium [14]. Delirium is a symptom, not a disease. If the patient is “alert and attentive” that essentially rules our delirium. You can detect delirium with the delirium triage screen and the bCAM [3,17]. The next step is to attempt to identify the cause(s) of delirium and then to prevent worsening, or prevent it in non-delirious patients [3]. For more on delirium, see an earlier podcast with Kevin Biese.Dementia is common, and frequently not recognized, but it plays an important part in the ED assessment and management of patients. Some potential tools include the Mini-Cog and Ottawa 3DY, which are <30 second validated screens that you can build into most assessments
  1. Polypharmacy [18]. Check out the Beers list of potentially high-risk medications, including things like NSAIDS, codeine, anti-cholinergics, benzos [3]. We’ve discussed high risk medications and potentially dangerous med combos on GEMCAST before. In general, “Start low, and go slow” is the mantra in geriatric medicine.
  1. Transitions of Care. The ED is not an island of care; it’s part of a continuum of multiple care providers for older people. Operations & outcomes will improve if you establish communication with upstream and downstream providers. Know what other members of the team (PT/OT/SW/Family doc/community care providers can contribute that complements or supplements emergency management. For example, is there a mechanism in your ED to have feedback and feed forward systems in place? If a clinic sends a patient to the ED, is there a way for them to get information to you about why the patient is there? If you see a patient in the ED and discharge them, is there a way to send info to the PCP that the patient had been there and what you did, what needs to be followed up, etc? Rather than re-invent the wheel when trying to communicate with other physicians, with nursing facilities, or outpatient services, or home health, having systems in place can help patients get the care they need.

The following three figures illustrate some of the factors that contribute to causing a fall, the inability to prevent a fall, and potential injuries or secondary effects from the fall.

Figure 01 Figure 02 Figure 03


  1. Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med. Feb 2013;29(1):31-47. http://www.ncbi.nlm.nih.gov/pubmed/23177599
  1. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geratr Soc. May 2007;55(5):780-791. http://www.ncbi.nlm.nih.gov/pubmed/1749320
  1. Rosenberg M, Carpenter CR, Bromley M, et al. Geriatric Emergency Department Guidelines. Ann Emerg Med. May 2014;63(5):e7-e25. http://www.ncbi.nlm.nih.gov/pubmed/24746437
  1. Sinha SK, Bessman ES, Flomenbaum N, Leff B. A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model. Ann Emerg Med. Jun 2011;57(6):672-682. http://www.ncbi.nlm.nih.gov/pubmed/21621093
  1. McCusker J, Verdon J, Vadeboncoeur A, et al. The elder-friendly emergency department assessment tool: development of a quality assessment tool for emergency department-based geriatric care. J Am Geriatr Soc. Aug 2012;60(8):1534-1539. http://www.ncbi.nlm.nih.gov/pubmed/22860623
  1. Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF. Physician and Nurse Acceptance of Geriatric Technicians to Screen for Geriatric Syndromes in the Emergency Department. West J Emerg Med. Dec 2011;12(4):489-495. http://www.ncbi.nlm.nih.gov/pubmed/22224145
  1. Hogan TM, Olade TO, Carpenter CR. A profile of acute care in an aging America: snowball sample identification and characterization of United States geriatric emergency departments in 2013. Acad Emerg Med. Mar 2014 21(3):337-346. http://www.ncbi.nlm.nih.gov/pubmed/24628759
  1. Tirrell G, Sri-on J, Lipsitz LA, Camargo CA, Kabrhel C, Liu SW. Evaluation of older adult patients with falls in the emergency department: discordance with national guidelines. Acad Emerg Med. Apr 2015 22(4):461-467. http://www.ncbi.nlm.nih.gov/pubmed/25773899
  1. Carpenter CR, Lo AX. Falling Behind? Understanding Implementation Science in Future Emergency Department Management Strategies for Geriatric Fall Prevention. Acad Emerg Med. Apr 2015 22(4):478-480. http://www.ncbi.nlm.nih.gov/pubmed/25773899
  1. Carpenter CR, Avidan MS, Wildes T, Stark S, Fowler S, Lo AX. Predicting Community-Dwelling Older Adult Falls Following an Episode of Emergency Department Care: A Systematic Review. Acad Emerg Med. Oct 2014 21(10):1069-1082. http://www.ncbi.nlm.nih.gov/pubmed/25293956
  1. Sirois MJ, Emond M, Ouellet MC, et al. Cumulative incidence of functional decline following minor injuries in previously independent older Canadian emergency department patients. J Am Geriatr Soc. 2013 61(10):1661-1668. http://www.ncbi.nlm.nih.gov/pubmed/24117285
  1. Carpenter CR. Deteriorating functional status in older adults after emergency department evaluation of minor trauma-opportunities and pragmatic challenges. J Am Geriatr Soc. Oct 2013;61(10):1806-1807. http://www.ncbi.nlm.nih.gov/pubmed/24117290
  1. Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive screening tools to detect cognitive impairment in geriatric emergency department patients: Brief Alzheimer’s Screen, Short Blessed Test, Ottawa3DY, and the Caregiver Administered AD8. Acad Emerg Med. Apr 2011 18(4):374-384. http://www.ncbi.nlm.nih.gov/pubmed/21496140
  1. Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. Mar 2009;16(3):193-200. http://www.ncbi.nlm.nih.gov/pubmed/21496140
  1. Han JH, Bryce SN, Ely EW, et al. The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Ann Emerg Med. Jun 2011;57(6):662-671. http://www.ncbi.nlm.nih.gov/pubmed/21272958
  1. Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an independent predictor of death within 6 months. Ann Emerg Med. Sep 2010;56(3):244-252. http://www.ncbi.nlm.nih.gov/pubmed/20363527
  1. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method. Ann Emerg Med. Nov 2013 62(5):457-465. http://www.ncbi.nlm.nih.gov/pubmed/23916018
  1. Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. Sep 2010;56(3):261-269. http://www.ncbi.nlm.nih.gov/pubmed/20619500
  1. Keyes DC, Singal B, Kropf CW, Fisk A. Impact of a New Senior Emergency Department on Emergency Department Recidivism, Rate of Hospital Admission, and Hospital Length of Stay. Ann Emerg Med. May 2014;63(5):517-524. http://www.ncbi.nlm.nih.gov/pubmed/24342817
  1. Platts-Mills TF, Glickman SW. Measuring the Value of a Senior Emergency Department: Making Sense of Health Outcomes and Health Costs. Ann Emerg Med. May 2014;63(5):525-527. http://www.ncbi.nlm.nih.gov/pubmed/24342812
  1. Neta G, Glasgow RE, Carpenter CR, et al. A Framework for Enhancing the Value of Research for Dissemination and Implementation. Am J Public Health. Jan 2015;105(1):49-57. http://www.ncbi.nlm.nih.gov/pubmed/25393182

 This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image [1]


Caso Spedali Civili di Brescia: Le Società scientifiche dell’emergenza presentano esposto in Procura



Simeu, Società italiana della medicina di emergenza-urgenza, insieme a Fimeuc, Federazione italiana della medicina di emergenza-urgenza e delle catastrofi e ad Acemc, Academy of emergency medicine and care hanno presentato un Esposto alla Procura di Brescia sulla questione del concorso per direttore di Pronto soccorso agli Spedali Civili di Brescia bandito lo scorso novembre.

Nell’Esposto le società scientifiche denunciano e ricostruiscono l’accaduto, sostenendo “l’illegittimità dell’operato dell’Azienda ospedaliera Spedali Civili di Brescia che ha messo a concorso un incarico quinquennale di direzione della struttura complessa di pronto soccorso individuando quale area interessata l’Area di medicina diagnostica e dei servizi e indicando quale disciplina Anestesia e Rianimazione, in palese contrasto con la normativa in materia, che colloca la struttura del pronto soccorso invece nell’Area medica e delle specialità mediche e indica come specialità di riferimento la Medicina e chirurgia di accettazione e d’urgenza ed equipollenti, fra cui non è riconosciuta Anestesia e Rianimazione”.

L’esposto si conclude con la richiesta alla Procura affinché indaghi sui fatti per i reati eventualmente ravvisabili.

Simeu agisce in questo caso insieme alle società scientifiche e associazioni federate in Fimeuc rappresentative dei medici che operano in tutte le strutture dell’emergenza sanitaria nazionale, fra cui Anaao-Assomed, Associazione medici dirigenti del Ssn, Cimo, Confederazione italiana medici ospedalieri, e Smi, Sindacato medici italiani.

La denuncia di Simeu del caso Brescia è stata avallata anche dall’intervento di due organizzazioni internazionali di settore, Eusem, European society for emergency medicine, e Uems, Union européenne des médicines spécialistes.

Un riassunto della vicenda su questo blog.

Asthma Starter Pack

It’s the beginning of a new academic year- and whether or not you are entering the ED for the first time, or returning after a hiatus it’s a good time to catch up on the basics. That’s what these “Starter Packs” are about. I have collated a number of different posts to give you an idea of what I’ve shared over the past few years on a number of common conditions. First up, asthma.


Albuterol MDI vs Nebs: Who’s Better


Why we do what we do: Systemic corticosteroids in acute asthma exacerbations

Are you giving asthmatics prednisone when you could be prescribing dexamethasone instead?


Why we do what we do: Intravenous magnesium for asthma exacerbations